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/ <br /> Waste Tire Vey & Inspection Rep"Inspection Report NumberState of <br /> ■ <br /> CalRecycle CalRecyclel1fornia 181(Rev.10/10) _ I1 - 1176480 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form Page 1 <br /> BLUE OR BLACK INK PEN <br /> PartA- Surve rte <br /> Business Profile Inspection Details <br /> TPID- q 1 1 S _ Inspection Type(Fill one) <br /> Site Suffix: 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: so,() V it n (DAM +!'► 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �.1 Inspected By Inspector <br /> Physical Address ` <br /> Inspection Date <br /> Sir o&A-o <br /> G A T5--tO Time In Time Out <br /> Business Rep Title i 0 AM 0 AM <br /> CI N 1 3 0 ®PM 0PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Cj <br /> ® Active Q Passenger (S Generator 4P Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other Far <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> u, <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments Q-Owk\(�, W,,c�-�,���Se, j J1`i]Q C14�01� D�T�C�rrcl O �1 rA �L�1V�"►�2J <br /> �o y u/fi1o�S QS��S L�nC�n. <br /> Inspection Form Included: 0 k 17 � Q <br /> Comments Included: 19 -- — - <br /> Busi ss Rep's Signature Phone Number Inspnr'sSignature Phone Number62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink © ■ <br />